Provider Demographics
NPI:1023621802
Name:GRONBOLDT, JULIE DIANA
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:DIANA
Last Name:GRONBOLDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:DIANA
Other - Last Name:HANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14201 BROAD OAKS CT
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4618
Mailing Address - Country:US
Mailing Address - Phone:804-312-6154
Mailing Address - Fax:
Practice Address - Street 1:14201 BROAD OAKS CT
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4618
Practice Address - Country:US
Practice Address - Phone:804-312-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000010225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist